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Inpatient Facility Coding & Compliance Alert

You Be the Coder:

Do Not Apply Critical Care Codes on Basis of Location Alone

Published on Thu Aug 14, 2014

Question: After a patient with severe abdominal pain and hemoptysis in the ER was admitted to the ICU, the provider saw the patient for a consult. The patient was lethargic and could not give a proper history, so most of his information came from prior medical records. The provider did not document time. Can we use codes for critical care since the patient was in the ICU?

California Subscriber

Answer: No, you cannot bill critical care (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...) simply because the place of service is the intensive care unit (ICU).
 
The service you describe would be an inpatient consultation, such as 99253 (Inpatient consultation for a new or established patient ...). For Medicare or other payers not accepting consultation codes, this would constitute an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).
 
Critical distinction: Critical care is not location-based; rather, it describes a specific kind of care. You must meet the following criteria to bill for critical care:
  • The patient must have a critical illness (usually defined as a critical organ system failure or a shock-like syndrome)
  • The physician must document a total of at least 30 minutes of time spent directly with the patient or on the floor (hospital unit) limited only for that patient
  • The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or prevent further deterioration of the patient’s condition.
  • Typically, the physician providing critical care monitors the patient for an extended time and obtains opinions and advice from multiple specialties to create an overall care plan.
Note: For physician coding the time spent providing critical care services may be in discrete time segments that can be added together.  On the facility side critical care services are contiguous. 

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